Notation of previous falls in admission record of hospitalized elderly.
Notation of previous falls in admission record of hospitalized elderly.
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住院老人入院记录中以前跌倒的记录。
DOI：
10.1007/bf03339636
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发表时间：
1998
期刊：
影响因子：
--
通讯作者：
Wei,JY
中科院分区：
文献类型：
--
作者：
Edelberg,HK;Lyman,K;Wei,JY
为了验证医生和护士少报跌倒史的假设，我们评估了入院病史中记录跌倒史的程度。对一家三级保健社区教学医院急诊病房和普通内科病房收治的168名社区居住和机构老年人进行了评估。医生和护士的急诊病房和入院记录被审查，包括“跌倒”。在入院后72小时内，对病历中提供或遗漏的信息进行面对面的确认或驳斥。后续数据从计算机记录中收集。样本人群包括113例患者，56%为女性，平均年龄80.7岁。过去10年内有76名患者患病；其中32例（42%）为近期患者，44例（58%）为多次患者。对医疗记录的审查显示，76名失踪者中有56人（74%）没有被医务人员注意到。此外，15例（47%）近期发病者和28例（64%）多发发病者未被发现。对护理记录的检查也得出了类似的结果。综上所述，老年患者摔倒的频率比人们认为的要高。医生和/或护士应将有关跌倒的问题作为常规病史的一部分。
To test the hypothesis that a history of falling is underreported by physicians and nurses, we assessed the extent to which previous falls are noted in the admission medical history. A total of 168 community-dwelling and institutionalized elderly adults, >-70 years old, were evaluated in the emergency ward of a tertiary care community-based teaching hospital, and admitted to a general medical ward. Physicians’ and nurses’ emergency ward and admission notes were reviewed for the inclusion of “falls.” Within 72 hours of admission, the information provided or omitted in the medical record was confirmed or refuted by face-to-face interview. Follow-up data were gleaned from computer-based records. The sample population consisted of 113 patients, 56% female, with a mean age of 80.7. Seventy-six patients had fallen within the past 10 years; of these, 32 (42%) were Recent Fallers, and 44 (58%) were Multiple Fallers. Review of the medical records revealed that 56 (74%) of the 76 Fallers were not noted to have fallen by the medical staff. Moreover, 15 (47%) of the Recent Fallers and 28 (64%) of the Multiple Fallers were missed. Examination of the nursing notes yielded similar results. In conclusion, elderly patients fall more frequently than recognized. Physicians and/or nurses should include a question regarding falls as part of the routine medical history.